Blue Choice Preferred Gold PPO Plans

Blue Choice Preferred Gold PPO Plans offers a respectable PPO network of doctors and hospitals and the convenience of never needing a referral to see a specialist. Blue Choice Preferred PPO Plans are coupled with the Blue Choice Preferred PPO network, a smaller version of the “standard” Blue Cross Blue Shield of Illinois PPO network that is was discontinued beginning January 1st, 2016. If you can accept some reduced hospital and physician choices, Blue Choice Preferred Gold PPO may be a great option for you.

The differences are how much your premium costs each month, what portion of the bill you pay for things like hospital visits or prescription medications, and how much your total out-of-pocket costs are. Blue Choice Preferred Gold PPO Plans have a higher monthly premium and often lower out-of-pocket costs than Blue Choice Preferred Silver plans.

Coinsurance of 100% to 80% percent of services provided in-network, after deductible and copayments are met

Annual out-of-pocket maximum of $3,250 and $3,500 for individuals and $9,750 or $10,500 for families, depending on the plan

By using a contracting BCBS PPO hospital, doctor or specialist you are able to save on premiums and the cost of covered services. You do not need to select a primary care physician or obtain a referral to see a specialist.

Plan Renewals

The plan is discontinued (90 days notice given with an option to convert to any plan we offer)

Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

If you no longer reside, live or work in an area where we are authorized to do business

Prescription Drug Coverage

For the Blue PPO Gold and Blue Choice Gold Plans, there is a prescription drug card benefit that includes a $0 or $10 copay for generic, $35 or $75 copay for formulary drugs, and a $150 copay for specialty medications. This benefit is immediately available and not subject to a deductible.

There is a also a Home Delivery prescription benefit available with these 3 deductible options where you can receive a 90 day supply in the mail for the cost of a 60 day supply and is subject to a maximum cost of $300 per prescription.

Outpatient Prescription Drug Benefit

Gold Plan 001

Gold Plan 002

Preferred Generics

$0 copay

$0 copay

Non-Preferred Generics

$10 copay

$10 copay

Preferred Formulary

$35 copay

$35 copay

Non-Preferred Formulary

$75 copay

$75 copay

Specialty

$150 copay

$150 copay

Home Delivery
Up to a 90-day supply of maintenance drugs is available through home delivery and is subject to $300 maximum per prescription.

Preferred Generics

$0 copay

$0 copay

Non-Preferred Generics

$20 copay

$20 copay

Preferred Formulary

$70 copay

$70 copay

Non-Preferred Formulary

$150 copay

$150 copay

Specialty

$300 copay

$300 copay

What’s Included with Blue PPO Gold Plans®

Coverage for major hospital, medical and surgical expenses incurred as a result of a covered accident or sickness

Although you can go to the hospital or doctor of your choice, your benefits under a Blue Choice Gold® plan will be higher, and your costs lower, when you use the services of participating BlueChoice® PPO providers.

Maternity Coverage

As with all individual Blue Cross and Blue Shield of Illinois plans, the freedom of not having to select a primary care doctor or obtain a referral to see a specialist

More Plan Details

It’s important to know the critical features of the health plan you are considering. Each plan’s Outline of Coverage provides brief descriptions of the basic provisions the Blue Choice Gold plans, as well as details on policy renewability, benefit exclusions and coverage limitations.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No.

You don’t have to meet deductibles for specific services, but see the chart starting on page 2 or other costs for services this plan covers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No. You don’t need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan document for additional information about excluded services.

Common Medical Event

Services You May Need

Your cost if you usea ParticipatingProvider

Your cost if you usea Non-ParticipatingProvider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$20 copayment/visit

50% coinsurance

First visit is no charge. No benefits will be provided for services which are not, in the reasonable judgment of Blue Cross and
Blue Shield, medically necessary

Specialist visit

$40 copayment/visit

50% coinsurance

—none—

Other practitioner office visit

$40 copayment/visit

50% coinsurance

Acupuncture not covered. Chiropractic and Osteopathic Manipulation are limited to 25 visits per calendar year.

Lower coinsurance applies at preferred
Participating pharmacies. Retail covers a 30 day supply and home delivery covers a 90 day supply. Certain women’s preventive services will be covered with no cost to the member.
For a full list of these prescriptions and/or services, please contact
Customer Service. Non-Participating home delivery is not covered.
Non-Participating specialty drug coverage is limited to certain medications that are clarified in the prescription drug rider. For Non-Participating drug provider, you are responsible for 50% of the eligible amount after the coinsurance. Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. Generic drugs are not subject to the deductible.

Non-formulary generic drugs

$10/$15 copayment/
prescription
$30 Home Delivery

$15 copayment/
prescription

Formulary brand drugs

$50/$60 copayment/
prescription
$150 Home Delivery

$60 copayment/
prescription

Non-formulary brand drugs

$100/$110
copayment/
prescription
$300 Home Delivery

$110 copayment/
prescription

Specialty drugs

30% coinsurance

50% coinsurance

If you have outpatientsurgery

Facility fee (e.g., ambulatory surgery center)

$200 copayment/visit
plus 30% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

Abortions not covered, except where a pregnancy is the result of rape or incest, or for a pregnancy which, as
Certified by a physician, places the woman in danger of death unless an abortion is performed.

Physician/surgeon fees

30% coinsurance

50% coinsurance

If you need immediatemedical attention

Emergency room services

$500 copayment/visit
plus 30% coinsurance

$500 copayment/visit
plus 30% coinsurance

Copayment waived if admitted.

Emergency medical transportation

30% coinsurance

30% coinsurance

Ground and air transportation covered.

Urgent care

$75 copayment/visit

50% coinsurance

—none—

If you have a hospitalstay

Facility fee (e.g., hospital room)

$300 copayment/visit
plus 30% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

Inpatient Services: Participating (Par),
member may be balance billed if preauthorization not received within
15 days prior. Non-Participating (Non-Par), $500 penalty if not preauthorized 2 business days prior.

Physician/surgeon fee

30% coinsurance

50% coinsurance

If you have mentalhealth, behavioralhealth, or substanceabuse needs

Mental/Behavioral health outpatient services

30%
coinsurance

50% coinsurance

Pre-authorization is required for Psychological testing; Neuropsychological testing;
Electroconvulsive therapy; Repetitive Transcranial magnetic Stimulation; and Intensive Outpatient Treatment.
Inpatient Services: Par, member may be balance billed if preauthorization not received within 15 days prior.
Non-Par, $500 penalty if not preauthorized 2 business days prior.
Outpatient Services: Par, member will
be responsible for the first $1,000 or
50%, whichever is less, if not preauthorized one business day prior. Non-Par, $500 penalty if not preauthorized one business day prior.

Mental/Behavioral health inpatient services

$300 copayment/visit
plus 30% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

Substance use disorder outpatient services

30% coinsurance

50% coinsurance

Substance use disorder inpatient services

$300 copayment/visit
plus 30% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

If you are pregnant

Prenatal and postnatal care

$20 copayment/visit

50% coinsurance

–none—

Delivery and all inpatient services

$300 copayment/visit
plus 30% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

If you need helprecovering or have other special health needs

Home health care

30% coinsurance

50% coinsurance

Inpatient Services: Par, member may
be balance billed if preauthorization not received within 15 days prior. Non-Par, $500 penalty if not preauthorized 2 business days prior.
Outpatient Services: Par, member will be responsible for the first $1,000 or 50%, whichever is less, if not preauthorized one business day prior.
Non-Par, $500 penalty if not preauthorized one business day prior.

Rehabilitation services

30% coinsurance

50% coinsurance

Habilitation services

30% coinsurance

50% coinsurance

Skilled nursing care

30% coinsurance

50% coinsurance

Durable medical equipment

30% coinsurance

50% coinsurance

Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price).

Hospice service

30% coinsurance

50% coinsurance

Inpatient Services: Par, member may be balance billed if preauthorization not received within 15 days prior. Non-Par, $500 penalty if not preauthorized 2 business days prior.

If your child needsdental or eye care

Eye exam

No Charge

Covered

One visit per year. Reimbursed up to
$30 out-of-network. See benefit booklet for network details.

Glasses

Covered

Covered

One pair of glasses per year. Reimbursed up to $45 out-of-network.
See benefit booklet for network details.